Healthcare Provider Details

I. General information

NPI: 1376522136
Provider Name (Legal Business Name): KYLE YOUNG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 02/08/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 S CONGRESS AVE SUITE 300
ATLANTIS FL
33462-1149
US

IV. Provider business mailing address

5301 S CONGRESS AVE SUITE 300
ATLANTIS FL
33462-1149
US

V. Phone/Fax

Practice location:
  • Phone: 561-548-4900
  • Fax: 561-548-4902
Mailing address:
  • Phone: 561-548-4900
  • Fax: 561-548-4902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1612-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: